Prevalence of depression and associated factors among HIV/AIDS patients attending antiretroviral therapy clinic at Adama Hospital Medical College, Adama, Central Ethiopia

Depression is the most frequently detected and preventable mental illness among people with human immunodeficiency syndrome, with rates two to four times higher than in the general population. Currently, depression is estimated to affect 350 million people worldwide. To assess the prevalence of depression and associated factors among HIV/AIDS patients attending antiretroviral therapy clinic at Adama Hospital Medical College, Adama, Central Ethiopia. An institutional-based cross-sectional study was conducted from April 01 to September 30, 2021, at Adama Hospital Medical College, Adama, Ethiopia. A total of 420 individuals were selected using a systematic random sampling technique. After informed consent was obtained from each study participant, data were collected through face-to-face interviews, observations, and document reviews. Subsequently, the data were entered into EPI-Info Version 7 and analyzed by Statistical Package for the Social Sciences version 21. Variables with p-values less than 0.25 in the univariable logistic regression analysis were subsequently included in the multivariable logistic regression analysis to account for potential confounding factors. The association was measured using adjusted odds ratio (AOR) with a 95% confidence interval (CI), and variables with p-values less than 0.05 were considered statistically significant. The prevalence of depression was 52.4% (95% CI 47.6–57.1). Factors significantly associated with depression among HIV-positive patients on antiretroviral therapy included employment status [AOR = 0.22(95% CI 0.13–0.36)], the patient’s most CD4 count [AOR = 6.99 (95% CI 2.81–17.38)], duration of months on antiretroviral therapy [AOR = 5.05 (95% CI 2.38–10.74)] and presence of chronic non-communicable diseases [AOR = 7.90 (95% CI 4.21–14.85)]. The highest proportion of HIV-positive patients taking antiretroviral drugs exhibited depression. Employment was identified as a preventive factor, whereas having a low CD4 count, recently initiating antiretroviral therapy, and having chronic non-communicable diseases were associated with increased odds of depression among HIV-positive patients on antiretroviral therapy. There need to strengthen mental health screening and treat depression among HIV-positive patients, particularly by targeting identified factors.


Sample size and sampling procedure
The sample size was computed using Epi Info 7 stat calc.Using a population survey formula proportion for a single population, assuming a level of confidence at 95% and margin of error at 5%, and based on a study done at Harari town, revealed a prevalence of 45.8% of depression 9 .A 10% non-response rate was added to obtain a maximum sample size, and the final sample size was 420.Systematic random sampling was used to select participants using the antiretroviral drug registration book as the sampling frame.An interval of k = N/n = 7000/420 = 16 was used to select the study participants.The first study participant was selected using the lottery method and then every 16th client was included.Study participants were invited to participate when attending the hospital for antiretroviral drug collection.

Data collection procedure and tools
Data were collected using an interviewer-administered questionnaire that covered socio-demographic, psychological, and social characteristics, the presence of chronic non-communicable diseases, health and nutritionrelated conditions, and Patient Health Questionnaire (PHQ-9).Depression was assessed using PHQ-9 quick depression assessment, which ranges from 0 to 27.The severity of depression was characterized as minimal (0-4), mild (5-9), moderate (10-14), moderately severe [15][16][17][18][19] and severe depression (≥ 20) 28 .The questionnaire was adapted from different kinds of literature 17,21,28 and was pre-tested on 5% of the study population in the non-selected hospital /Bishoftu Hospital/ to ensure clarity, wording, logical sequence, and skip patterns of the questions.The questionnaire was prepared in English and then translated into local language (Afaan Oromo) and Amharic by language experts.To ensure consistency, the Afaan Oromo version was translated back into English.Data was collected using both an Afaan Oromo and Amharic language questionnaire based on the patient's preferences.
Four BSc nurses were recruited as data collectors, and one master's degree holder was assigned as the supervisor.The training was given to data collectors and supervisor for one day on data collection methods, how to take informed consent, how to approach participants, ethical procedures, and general information on the depression grade of HIV patients taking ART, and the study's objective.Face-to-face interview, observation and document review was done to collect the data.Document review were used to fill in information like CD4 count, Viral load, and WHO clinical staging.The collected data underwent daily checks for activity, consistency, and questionnaire completeness to ensure data quality.Incomplete or unfilled questionnaires were not accepted.

Data analysis methods
After data collection, a questionnaire was checked for missed data and errors, and then data was entered into Epi-info version 7 and analyzed using the statistical package for Social Science (SPSS) version 21.The data were cleaned and prepared for analysis.Descriptive statistics such as frequency, mean, and standard deviation describe the study's variables.A binary logistic regression model was used to ascertain the relationship between the independent variables and the outcome variable.Assumptions for logistic regression were considered, and model fitness was tested by Hosmer and Lemeshow goodness-of-fit test statistic and was born at greater than 0.05.Before including factors, multicollinearity was checked using the cutoff point, variance inflation factor (VIF) < 10.Factors with a p-value less than 0.25 in the univariable logistic regression analysis were further entered into the multivariable analysis to control for potential confounders.Adjusted Odds Ratio with 95% CI was used to measure association, and p-values less than 0.05 were taken as statistically significant.Finally, the results of the findings were presented using text, graphs and tables.

Ethical considerations
The study was approved by Addis Ababa University institutional review board, and a formal letter of permission was obtained from Addis Ababa University, the school of public health with registration number SHP/0023/13.An official letter of cooperation was written from Addis Ababa University to Oromia Regional Health Bureau, which then wrote to the respective health facility.There is no potential risk that may cause any harm to respondents.All the necessary precaution for COVID-19 prevention was kept during data collection.The importance of the study was explained to the study participants, and informed written consent was requested from the subjects included in the survey immediately before the data collection with the subjects full right to refuse the interview at any time if they did not want to proceed.The respondents were informed that they would not lose anything (do not affect their treatment regimen) for not participating in the study.Patients who were diagnosed with depression during data collection were linked to a psychiatry unit for further evaluation and treatment.

Operational definition
Depression:-a person who scores in the PHQ-9 greater or equal to the cutoff point of 5 and has a common mental illness that negatively affects how they feel, the way they think and how they act 28 .
Good adhered to ART drugs:-patients who take ≥ 95% of the prescribed dose were considered adherent to medication as stated in Ethiopian consolidated ART guideline 29 .
Mody Mass Index (MBI): underweight if the patient had a BMI < 18.5 kg/m 2 , normal weight if the patient had a BMI between 18.5 and 24.9 kg/m 2 and overweight if the patient had a BMI > 25.0 kg/m 230 .

Health and nutrition related conditions of HIV-positive patients
Nearly half, 51.7% (n = 217) of the study participants were concordant positive and one-third, 33.3% (n = 140) of the HIV-positive patients don't know their partner's HIV status.Regarding viral suppression, 95.5% (n = 401) of the participants had a viral load of < 1000 copies/mm 3 .Nearly two-thirds, 63.8% (n = 268) of the patients presented with CD4 < 200 cells/mm 3 at diagnosis.Regarding the most recent CD4, 37.9% (n = 159) of the study participants had ≥ 500 cells/mm 3 .The majority, 79.5% (n = 334) of the HIV-positive patients, were in the stage 1 WHO clinical stage.Nearly one-third, 36.9% (n = 155)of HIV-positive patients had ever developed an

Factors associated with depression among HIV-positive patients
The univariable logistic regression analysis revealed that depression among HIV-positive patients had an association with the educational level of the patients, work status, chewing chat, family history of psychiatric illness, patient's most recent CD4 count, months on ART and presence of chronic non-communicable diseases.Those variables with a p-value of less than 0.25 in the simple logistic regression analysis were entered in multivariable logistic regression analysis.In multivariable logistic regression analysis, work status, patient's most recent CD4  The odds of employed patients having depressive symptoms were 78% [AOR = 0.22(95% CI 0.13-0.36)]lesser than unemployed patients.HIV-positive patients who had the most recent CD4 count < 200 cells/mm 3 were seven times [AOR = 6.99 (95%CI 2.81-17.38)]more likely to have depression than patients with CD4 count ≥ 500 cells/ mm 3 .Patients who received ART for ≤ 24 months were five times [AOR = 5.05 (2.38-10.74)]more likely to have depression than their counterparts.HIV-positive patients with co-morbid chronic non-communicable disease were eight times [AOR = 7.90 (4.21-14.85)]more likely to have depression than their counterparts (Table 5).

Discussion
This study set out to examine the prevalence and factors associated with depression among patients taking antiretroviral drugs in the study setting.We found that 52.4% of HIV-positive patients taking ART had depression.This finding is comparable with a study conducted in India (57%) 6 , Hawassa (55.8%) 19 , Western Uganda (46%) 13 , and Harar town (45.8%) 21.This finding is higher than a study done in China (40.9%) 7 , Gimbi (41.7%) 22 , Alert Hospital (41.2%) 31 , Debrebrihan referral hospital (38.9%) 23 , Addis Ababa (35.5%) 24 , Somalia (33%) 14 , Pakistan (32.2%) 8 ,  25 , and Debremarkos town (11.7%) 26 .This might be due to differences in socioeconomic status, study period, sample size, the studied population, and data collection tools.For instance, the study conducted in China 7 used the burn depression checklist, Western Uganda 13 used the Center for Epidemiological Studies' depression scale, Addis Ababa 24 used the Beck depression inventory-II, and we used PHQ-9.The employed patients were 78% less likely to have depression than unemployed patients.This finding was supported by a study conducted in Nigeria and Cameroon that revealed unemployment and low income were associated with depression among people living with HIV 15,32 .This might be because being employed will reduce the socioeconomic burden that might impose additional stress on HIV-positive patients.This double burden of stress might lead the patients to depressive disorder.
HIV-positive patients with the most recent CD4 count ≤ 200 cells/mm 3 were seven times more likely to have depression than patients with CD4 count ≥ 500 cells/mm 3 .This finding was consistent with a study conducted in a tertiary hospital in South Western Nigeria, Cameroon and by the centers for AIDS research 15,32,33 .This might be because low CD4 count might be associated with opportunistic infections, which further bring additional worries, stress and physical disabilities.
Patients taking ART for ≤ 24 months were five times more likely to have depression than their counterparts.This finding was in line with a study conducted in rural Uganda and Spanish 34,35 .This might be attributed to ongoing counseling and support the patients might receive about HIV diagnosis and treatment, which might reduce mental stress and anxiety leading to depressive symptoms.www.nature.com/scientificreports/HIV-positive patients with at least one co-morbid chronic non-communicable disease (diabetes, hypertension, cardiac diseases and asthma) were eight times more likely to have depression than their counterparts.This finding was supported by a study conducted by Watkins CC and Treisman GJ in Johns Hopkins Hospital, which found neuropsychiatric symptoms, including depression, cognitive impairment, and substance abuse, are common among HIV-infected patients with chronic co-morbid conditions 36 .This might be due to co-morbid chronic noncommunicable diseases, which will add tremendous pressure to the existing challenge in the fight against HIV.

Limitations of the study
The study's cross-sectional design makes it impossible to determine the temporal link between various factors and depression.Because the study was conducted in a hospital, the results may not apply or generalize to the entire population.We performed quantitative research to assess factors associated with depression among HIV patients.If qualitative methods, such as focus groups and in-depth interviews, had been combined with this quantitative study, more information concerning depression among HIV-positive patients would have been identified.Furthermore, hormonal tests like thyroid function tests, serum cortisol, testosterone, estrogen, and progesterone levels, all of which might be associated with depression, were not available in this hospital during the study.

Conclusion
A significant proportion, 52.4% of HIV-positive patients taking ART, had depression.Patient employment status, most recent CD4 count, months on ART, and chronic non-communicable diseases were factors associated with depression among HIV-positive patients.Employed patients were less likely to have depression.However, patients with most CD4 counts of less than 200 cells/mm 3 and those who took ART for ≤ 24 months and had chronic non-communicable diseases were at increased risk of developing depression.

Recommendation
The Ministry of Health and partners working on HIV need to strengthen mental health screening and treat depression among PLWHA with due attention on unemployed patients, low CD4 count, patients newly initiated on ART and with co-morbid chronic non-communicable patients.Further longitudinal research on risk factors of depression should be conducted to strengthen and broaden the current findings.

Figure 1 .
Figure 1.Severity of depression among HIV-positive patients taking ART at Adama Hospital Medical College, 2021.

Figure 2 .
Figure 2. Prevalence of depression among HIV-positive patients taking ART at Adama Hospital Medical College, 2021.

Table 1 .
Socio-demographic characteristics of patients taking ART in Adama Hospital Medical College, 2021.

Table 2 .
Psychological and social characteristics of patients taking ART in Adama Hospital Medical College, 2021.

Table 3 .
Presence of chronic Non-communicable diseases among patients taking ART in Adama hospital medical college, 2021.

Table 4 .
Health and Nutrition related conditions of patients taking ART in Adama Hospital Medical College, 2021.